This report is one section of State Strategies to Leverage Medicaid Managed Care Contracting for Investments in Health and Housing Alignment. See the full resource guide.
For more information on financing housing-related services, please visit our Medicaid and Housing toolkit.
Recognizing that many systems must come together to effectively coordinate health and housing services, states are requiring MCOs to collaborate closely with housing system partners who have extensive experience in this work. Several states have language in their contracts that require or encourage MCOs to invest in housing systems, with specific requirements to invest in community-identified priorities or collaborate with certain housing partners.
Participate in Community Planning
A handful of states require or incentivize MCOs to support identification of resources and assets in the community they serve. For instance, Oregon requires its MCOs (called coordinated care organizations or CCOs) to work closely with communities to support housing-related planning efforts. Since 2012, Oregon has fostered partnerships between its CCOs and community-based organizations (CBOs) to reduce health inequities by addressing both individual CCO enrollees’ and community social needs. In 2020, Oregon launched CCO 2.0, which built on several policies that were already in place in the 1.0 phase intended to strengthen CCO/CBO partnerships.
To support planning efforts and understand the resource landscape, Oregon’s CCOs are required to conduct a community health assessment, develop and implement a community health improvement plan, and establish a community advisory council (CAC). As part of CCO 2.0, the current contract also requires that social drivers of health and equity (SDOH-E) partners and organizations be included in the development of both the assessment and improvement plan. An SDOH-E partner is an entity, including a CBO, that “delivers SDOH-E related services or programs, or supports policy and systems change, or both within a CCO’s service area” (p. 264, Exhibit K of 2024 CCO Contract). Payment for these efforts is discussed further in the section titled “Paying MCOs to Address Housing Challenges.”
Invest Profits into Housing Resources
Several states require Medicaid MCOs to reinvest a portion of their revenues directly into the communities being served and/or into specific programs. Many MCOs are leveraging this opportunity to identify top community priorities and, in some cases, invest directly in housing resources. For example:
Ohio
The Ohio Department of Medicaid (ODM) requires MCOs to contribute 3 percent of their annual after-tax profits to community reinvestment, and the percentage of contributions must increase by 1 percent each subsequent year until it reaches 5 percent. Community reinvestment initiatives began in 2023 based on the first annual period from January to December 2023. MCOs must prioritize community reinvestment opportunities generated from community partners and use available population health data (e.g., opportunity index data) and consider existing local community health assessments to develop its community reinvestment plan. Additionally, MCOs are required to collaborate with other MCOs and evaluate the impact of community reinvestment efforts (p. 137 of Provider Agreement). Community reinvestment is a key activity within ODM’s Population Health Approach, which focuses on addressing housing instability, among other social determinants of health (SDOH) and initiatives for cross-system collaboration.
Mississippi
In Mississippi’s draft contract for its next Managed Care Request for Qualifications, the state requires MCOs to devote at least a half percent of capitation payments to SDOH projects and work with CBO partners to develop and administer those initiatives (p. 215 of 2021 Coordinated Care Model contract). The draft contract’s SDOH strategy refers to homeless shelters and CBOs addressing housing needs as examples of partners in this work. The contract has not yet been implemented.
Oregon
Through Oregon’s SHARE initiative (Supporting Health for All through REinvestment), coordinated care organizations (CCOs) must spend a portion of their net income on SDOH-E efforts in their community. Investments with community SDOH-E partners must be based on priorities in the CCO’s current community health improvement plan, include a role for the CCO’s community advisory council (CAC) in CCO spending decisions, fit into one of four domains (economic stability, neighborhood and built environment, education, and social and community health), and address the Oregon Health Authority-designated statewide priority (which is currently housing-related services and supports) (p. 273, Exhibit K of 2024 CCO Contract). An example of such an investment from the Oregon Health Authority includes “investing in low-income housing units with wraparound supports on site.”
Dedicate Resources to Maintain Relationships with Housing Partners
Many states require MCOs to develop written agreements or regular touch points with housing providers or other housing partners. A handful of states require or incentivize partnerships with certain types of entities. The most prescriptive contracts require MCOs to form partnerships with specific entities or require an MCO to employ someone whose position is dedicated to collaborating with housing partners.
Arizona
Arizona requires MCOs to employ a housing specialist or community liaison who serves as an expert on housing resources within an MCO’s service area and coordinates with housing partners and other systems to address an enrollee’s unmet housing needs. Arizona housing specialists are required to partner with provider networks’ support staff (e.g., case managers) to provide education and support to enrollees in accessing their independent living housing options (the contract lists specific housing programs). Additionally, the housing specialist is the MCO’s liaison to the state Medicaid agency’s quarterly Housing Coordination Meetings and other ad hoc housing workgroups and initiatives. They are also the liaison to the Continuum of Care (CoC, i.e., local entities that coordinate a community’s homelessness response and receive funding from the U.S. Department of Housing and Urban Development) in the MCO’s service area, must attend relevant CoC meetings, and participate in coordinated entry and the Homeless Management Information System (HMIS, see more details in the following section). The contract further specifies that MCOs must ensure that the housing specialist is familiar with certain standards and practices related to permanent supportive housing (PSH), including state and federal Fair Housing laws and the fundamentals of Housing First and the Substance Abuse and Mental Health Services Administration (SAMHSA) PSH program, among other practices (p. 123 of ACC contract).
California
California requires MCOs to develop a robust provider network to deliver Community Supports (which includes housing services and supports, as outlined in the next section), and MCOs must enter into subcontractor or network provider agreements with these providers. MCOs are also required to partner to ensure that Community Supports providers have sufficient capacity to receive referrals and to support Community Supports providers in accessing systems and processes that allow them to obtain and document MCO enrollees’ information and notify MCOs when a referral has been fulfilled (p. 227, Exhibit A, Attachment 22, Provisions 20-21 of Medi-Cal Managed Care contract). MCOs are not required to provide community supports but are strongly encouraged to do so by the state Medicaid agency. Payment for Community Supports is discussed in the section titled “Paying MCOs to Address Housing Challenges.”
Pennsylvania
Pennsylvania requires its Physical Health MCOs to incorporate community-based organizations into value-based payment arrangements to address SDOH (p. 158 of 2023 HealthChoices Agreement). The MCO contract specifies certain percentages of capitation revenues that must be spent on CBOs addressing SDOH domains such as housing.
Acknowledgements
The authors would like to thank Robin Wagner, Elaine Chhean, and all the state officials who reviewed this brief for their thoughtful feedback. This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the National Organizations of State and Local Officials as part of a three-year award totaling $2,632,044 with 0% financed with non-governmental sources. The information, content, and conclusions are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
